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For the work on quercetin and mitochondria, a next step could be to analyse the effects in the muscle model to see if they are consistent or cell/tissue-specific. Mitochondrial assays were already tested on the LHCN-M2 myotubes and so this would be straightforward to set up. Furthermore, the metabolites for which effects on glucose metabolism were seen in the muscle could be tested for their potential roles in mitochondrial function too. The effects of quercetin were dose-dependent, with effects on complex I activity and ROS levels seen with 2.5 µM; any lower and the effects would likely not have been detected. To investigate effects even closer to the typical physiological range, a model could be established to try growing the HepG2 cells for a longer period (and/or through multiple passages) and treating with quercetin long-term i.e. daily treatments with 1 µM or even 0.1 µM, to see if changes are detectable in these assays, with comparisons to the 24 h treatments with 10 µM. Further investigations into the effects of quercetin on metabolic flux could be investigated using ion chromatography; analyses of lactate, pyruvate, succinate, citrate and so on would be interesting in the current HepG2 system and one would hypothesise seeing quercetin driving flux away from the glycolytic-dependent ATP synthesis towards the TCA cycle and mitochondrial respiration. Extracellular metabolites were measured by high- performance liquid chromatography recently (Niklas, Nonnenmacher et al. 2012) and this could be taken further by measuring intracellular metabolites in cell lysate extracts as well as the extracellular in the media, and comparing normal and high glucose. Furthermore, the effects on mitochondria will affect lipid metabolism as well as glucose, so analysis of the lipidome in HepG2 grown in normal and high glucose and treated with quercetin would be an interesting additional study; quercetin was already shown to exert lipid-lowering effects in the livers of diabetic mice via increased mitochondrial function (Kim, Kwon et al. 2015).

It would be challenging to investigate the effects of quercetin on hepatic mitochondria in

vivo for obvious reasons; mitochondria could be isolated from rodent livers following

quercetin intervention for example, but this certainly wouldn’t be possible in humans. An in vitro setup could involve obtaining primary hepatocytes from normal and diabetic patients and treating these with quercetin to see how the effects compare, but this heavily relies on tissue availability and a large cohort to see beyond inter-individual variability. An easier ex vivo approach may be to take muscle biopsies following a long-term quercetin intervention and analyse the samples on the high-resolution respirometer and/or isolate mitochondria from the tissue.

The obvious studies to be carried out next for the effects of (poly)phenol metabolites on glucose uptake and metabolism are human interventions. With an in vitro mechanism of action established for IVAS, this would be a promising compound to start with. An intervention with the berry purée used in the studies by Pimpão et al. (Pimpao, Dew et al. 2014, Pimpao, Ventura et al. 2015), from which the phenolic sulfate profile in this study was selected, may lower glycaemia in participants, though it would be unclear if this was an effect on muscle uptake or more so on the inhibition of carbohydrate digestion and absorption seen with berries in previous interventions (Nyambe-Silavwe and Williamson 2016). Intervention with a cyanidin 3-O-glucoside tablet, such as that used in pharmacokinetic studies (Czank, Cassidy et al. 2013, de Ferrars, Czank et al. 2014), instead of berries may result in more specific metabolites at least, or encapsulating IVAS so a controlled dose reaches the bloodstream.

Finally, to expand on the beneficial roles of (poly)phenol metabolites, and to make the

in vitro models closer to the in vivo situation, the HepG2 and/or LHCN-M2 cells could

be transfected with OAT-expressing plasmids to upregulate the transporters associated with the facilitated uptake of the sulfated conjugates (Wong, Akiyama et al. 2012). In the muscle study here the sulfated conjugates were not taken up and their effects may differ if they were. It would also be interesting to compare the effects of quercetin aglycone and quercetin 3′-O-sulfate on the mitochondrial function and cellular metabolism in HepG2 cells. Likewise, LHCN-M2 transfected with GLUT4 to increase expression beyond the low endogenous level would further confirm the GLUT4 translocation- stimulated mechanism of IVAS and other metabolites.

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